- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $2,884.03
| Professional | | $933.25 | $1,071.52 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $1,737.80
| Professional | | $933.25 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,137.96
| Professional | | $1,174.90 | $1,584.89 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,290.87
| Professional | | $891.25 | $1,318.26 | $2,290.87 |